Engagement of Children who are Deaf or Hard-of-Hearing Attending Mainstream Schools.

This study compared the observed and the self-reported engagement of 16 students who are Deaf or hard-of-hearing (DHH) attending mainstream schools to that of matched controls with typical hearing. Observed engagement was measured through observations in the classroom setting using the Mainstream Version of the Code for Instructional Structure and Student Academic Reponses. Self-reported engagement was measured using the Classroom Participation Questionnaire. The results revealed no significant differences for either observed or self-reported engagement between the DHH and the control groups; however, three individual DHH participants had lower levels of observed engagement compared to their matched controls. As such, including engagement in the evaluation of students who are DHH may be important for some individuals to provide a better understanding of the daily challenges they experience at school. Where needs are identified, the support that students who are DHH receive should include a specific focus on engagement to assist with their successful inclusion.

Academic Outcomes 2 Years After Working Memory Training for Children With Low Working Memory: A Randomized Clinical Trial.

IMPORTANCE: Working memory training may help children with attention and learning difficulties, but robust evidence from population-level randomized controlled clinical trials is lacking. OBJECTIVE: To test whether a computerized adaptive working memory intervention program improves long-term academic outcomes of children 6 to 7 years of age with low working memory compared with usual classroom teaching. DESIGN, SETTING, AND PARTICIPANTS: Population-based randomized controlled clinical trial of first graders from 44 schools in Melbourne, Australia, who underwent a verbal and visuospatial working memory screening. Children were classified as having low working memory if their scores were below the 15th percentile on either the Backward Digit Recall or Mister X subtest from the Automated Working Memory Assessment, or if their scores were below the 25th percentile on both. These children were randomly assigned by an independent statistician to either an intervention or a control arm using a concealed computerized random number sequence. Researchers were blinded to group assignment at time of screening. We conducted our trial from March 1, 2012, to February 1, 2015; our final analysis was on October 30, 2015. We used intention-to-treat analyses. INTERVENTION: Cogmed working memory training, comprising 20 to 25 training sessions of 45 minutes' duration at school. MAIN OUTCOMES AND MEASURES: Directly assessed (at 12 and 24 months) academic outcomes (reading, math, and spelling scores as primary outcomes) and working memory (also assessed at 6 months); parent-, teacher-, and child-reported behavioral and social-emotional functioning and quality of life; and intervention costs. RESULTS: Of 1723 children screened (mean [SD] age, 6.9 [0.4] years), 226 were randomized to each arm (452 total), with 90% retention at 1 year and 88% retention at 2 years; 90.3% of children in the intervention arm completed at least 20 sessions. Of the 4 short-term and working memory outcomes, 1 outcome (visuospatial short-term memory) benefited the children at 6 months (effect size, 0.43 [95% CI, 0.25-0.62]) and 12 months (effect size, 0.49 [95% CI, 0.28-0.70]), but not at 24 months. There were no benefits to any other outcomes; in fact, the math scores of the children in the intervention arm were worse at 2 years (mean difference, -3.0 [95% CI, -5.4 to -0.7]; P = .01). Intervention costs were A$1035 per child. CONCLUSIONS AND RELEVANCE: Working memory screening of children 6 to 7 years of age is feasible, and an adaptive working memory training program may temporarily improve visuospatial short-term memory. Given the loss of classroom time, cost, and lack of lasting benefit, we cannot recommend population-based delivery of Cogmed within a screening paradigm. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000486022.

Population Outcomes of Three Approaches to Detection of Congenital Hearing Loss.

BACKGROUND: Universal newborn hearing screening was implemented worldwide largely on modeled, not measured, long-term benefits. Comparative quantification of population benefits would justify its high cost. METHODS: Natural experiment comparing 3 population approaches to detecting bilateral congenital hearing loss (>25 dB, better ear) in Australian states with similar demographics and services: (1) universal newborn hearing screening, New South Wales 2003-2005, n = 69; (2) Risk factor screening (neonatal intensive care screening + universal risk factor referral), Victoria 2003-2005, n = 65; and (3) largely opportunistic detection, Victoria 1991-1993, n = 86. Children in (1) and (2) were followed at age 5 to 6 years and in (3) at 7 to 8 years. Outcomes were compared between states using adjusted linear regression. RESULTS: Children were diagnosed younger with universal than risk factor screening (adjusted mean difference -8.0 months, 95% confidence interval -12.3 to -3.7). For children without intellectual disability, moving from opportunistic to risk factor to universal screening incrementally improved age of diagnosis (22.5 vs 16.2 vs 8.1 months, P < .001), receptive (81.8 vs 83.0 vs 88.9, P = .05) and expressive (74.9 vs 80.7 vs 89.3, P < .001) language and receptive vocabulary (79.4 vs 83.8 vs 91.5, P < .001); these nonetheless remained well short of cognition (mean 103.4, SD 15.2). Behavior and health-related quality of life were unaffected. CONCLUSIONS: With new randomized trials unlikely, this may represent the most definitive population-based evidence supporting universal newborn hearing screening. Although outperforming risk factor screening, school entry language still lagged cognitive abilities by nearly a SD. Prompt intervention and efficacy research are needed for children to reach their potential.

The cost-effectiveness of universal newborn screening for bilateral permanent congenital hearing impairment: systematic review.

OBJECTIVE: Universal newborn hearing screening for bilateral permanent congenital hearing impairment is standard practice in many developed economies, but until there is clear evidence of cost-effectiveness, it remains a controversial use of limited health care resources. We conducted a formal systematic review of studies of newborn hearing screening that considered both costs and outcomes to produce a summary of the available evidence and to determine whether there was a need for further research. METHODS: A search was conducted of medical and nursing databases and gray literature websites by the use of multiple keywords. The titles and abstracts of studies were examined for preliminary inclusion if reference was made to newborn hearing screening, and to both costs and outcomes. Studies of potential relevance were independently assessed by 2 health economists for final inclusion in the review. Studies that met inclusion criteria were appraised by the use of existing guidelines for observational studies, economic evaluations and decision analytic models, and reported in a narrative literature review. RESULTS: There were 22 distinct observational or modeled evaluations of which only 2 clearly compared universal newborn hearing screening to risk factor screening for bilateral permanent congenital hearing impairment. Of these, the single evaluation that examined long-term costs and outcomes found that universal newborn hearing screening could be cost-saving if early intervention led to a substantial reduction in future treatment costs and productivity losses. CONCLUSIONS: There are only a small number of economic evaluations that have examined the long-term cost-effectiveness of universal newborn hearing screening. This is partly attributable to ongoing uncertainty about the benefits gained from the early detection and treatment of bilateral permanent congenital hearing impairment. There is a clear need for further research on long-term costs and outcomes to establish the cost-effectiveness of universal newborn hearing screening in relation to other approaches to screening, and to establish whether it is a good long term investment.

Can improving working memory prevent academic difficulties? A school based randomised controlled trial.

BACKGROUND: Low academic achievement is common and is associated with adverse outcomes such as grade repetition, behavioural disorders and unemployment. The ability to accurately identify these children and intervene before they experience academic failure would be a major advance over the current 'wait to fail' model. Recent research suggests that a possible modifiable factor for low academic achievement is working memory, the ability to temporarily store and manipulate information in a 'mental workspace'. Children with working memory difficulties are at high risk of academic failure. It has recently been demonstrated that working memory can be improved with adaptive training tasks that encourage improvements in working memory capacity. Our trial will determine whether the intervention is efficacious as a selective prevention strategy for young children at risk of academic difficulties and is cost-effective. METHODS/DESIGN: This randomised controlled trial aims to recruit 440 children with low working memory after a school-based screening of 2880 children in Grade one. We will approach caregivers of all children from 48 participating primary schools in metropolitan Melbourne for consent. Children with low working memory will be randomised to usual care or the intervention. The intervention will consist of 25 computerised working memory training sessions, which take approximately 35 minutes each to complete. Follow-up of children will be conducted at 6, 12 and 24 months post-randomisation through child face-to-face assessment, parent and teacher surveys and data from government authorities. The primary outcome is academic achievement at 12 and 24 months, and other outcomes include child behaviour, attention, health-related quality of life, working memory, and health and educational service utilisation. DISCUSSION: A successful start to formal learning in school sets the stage for future academic, psychological and economic well-being. If this preventive intervention can be shown to be efficacious, then we will have the potential to prevent academic underachievement in large numbers of at-risk children, to offer a ready-to-use intervention to the Australian school system and to build international research partnerships along the health-education interface, in order to carry our further studies of effectiveness and generalisability.

Slight-mild sensorineural hearing loss in children: audiometric, clinical, and risk factor profiles.

OBJECTIVES: Slight or mild hearing loss has been posited as a factor affecting speech, language, learning, and academic outcomes, but the risk factors for slight-mild sensorineural hearing loss (SNHL) have not been ascertained. The two specific aims for this research were (1) to describe the audiometric and clinical characteristics of children identified with slight-mild bilateral SNHL and (2) to compare children with slight-mild SNHL with those with normal hearing (NH) with respect to potential risk factors for congenital or acquired for hearing loss. DESIGN: A cross-sectional cluster sample survey of 6581 children enrolled in years 1 and 5 of Australian elementary school was completed. Children were screened for slight-mild SNHL, defined as a low- and/or high-frequency pure-tone average of 16 to 40 dB HL in the better ear, with air-bone gaps <10 dB. Children who did not pass the screen received air and bone conduction threshold and tympanometry tests to determine the type and degree of hearing loss. The parents of every child who participated in this study completed a questionnaire, before the hearing screening, to ascertain possible risk indicators. The questionnaire included items regarding the family's demographics, hearing status of family members, the presence of risk factors, and parental concern regarding the child's hearing. RESULTS: Fifty-five children with slight-mild SNHL and 5490 with NH were identified. Of the group with SNHL, 39 children had a slight loss (16 to 25 dB HL) and 16 had a mild loss (26 to 40 dB HL). The majority of the losses were bilateral and symmetrical, and the mean pure-tone average for the better ear for all 55 children was 22.4 dB HL (SD, 5.2). The most prevalent risk factor was "neonatal intensive care unit/special care nursery admission," which was reported for 12.5% of the SNHL and 8.4% of the NH group. Reported use of personal stereos was a significant risk factor with an odds ratio of 1.7 (95% confidence interval = 1.0 to 3.0, p = 0.05). The questions relating to parental concern for their child's hearing had low sensitivity (<30%) and very low positive predictive values (<3%) for detecting slight-mild SNHL. CONCLUSIONS: Slight-mild SNHL had a prevalence of 0.88% among the school-aged population sampled, with the majority of these children exhibiting bilateral, symmetrical audiometric configurations. Conventional risk factors for hearing loss were not strongly predictive of slight-mild SNHL nor were parental concerns about the child's hearing ability. The association between slight-mild SNHL and the parent report of personal stereo use suggests that this type of noise exposure may be a risk factor for acquired hearing loss. This seems to be the first documentation of such an association in a large sample of young children.

Spoken language development in oral preschool children with permanent childhood deafness.

This article documented spoken language outcomes for preschool children with hearing loss and examined the relationships between language abilities and characteristics of children such as degree of hearing loss, cognitive abilities, age at entry to early intervention, and parent involvement in children's intervention programs. Participants were evaluated using a combination of the Child Development Inventory, the Peabody Picture Vocabulary Test, and the Preschool Clinical Evaluation of Language Fundamentals depending on their age at the time of assessment. Maternal education, cognitive ability, and family involvement were also measured. Over half of the children who participated in this study had poor language outcomes overall. No significant differences were found in language outcomes on any of the measures for children who were diagnosed early and those diagnosed later. Multiple regression analyses showed that family participation, degree of hearing loss, and cognitive ability significantly predicted language outcomes and together accounted for almost 60% of the variance in scores. This article highlights the importance of family participation in intervention programs to enable children to achieve optimal language outcomes. Further work may clarify the effects of early diagnosis on language outcomes for preschool children.

Slight/mild sensorineural hearing loss in children.

OBJECTIVE: The goal was to determine the prevalence and effects of slight/mild bilateral sensorineural hearing loss among children in elementary school. METHODS: A cross-sectional, cluster-sample survey of 6581 children (response: 85%; grade 1: n = 3367; grade 5: n = 3214) in 89 schools in Melbourne, Australia, was performed. Slight/mild bilateral sensorineural hearing loss was defined as a low-frequency pure-tone average across 0.5, 1, and 2 kHz and/or a high-frequency pure-tone average across 3, 4, and 6 kHz of 16 to 40 dB hearing level in the better ear, with air/bone-conduction gaps of < 10 dB. Parents reported children's health-related quality of life and behavior. Each child with slight/mild bilateral sensorineural hearing loss, matched to 2 normally hearing children (low-frequency pure-tone average and high-frequency pure-tone average of < or = 15 dB hearing level in both ears), completed standardized assessments. Whole-sample comparisons were adjusted for type of school, grade level, and gender, and matched-sample comparisons were adjusted for nonverbal IQ scores. RESULTS: Fifty-five children (0.88%) had slight/mild bilateral sensorineural hearing loss. Children with and without sensorineural hearing loss scored similarly in language (mean: 97.2 vs 99.7), reading (101.1 vs 102.8), behavior (8.4 vs 7.0), and parent- and child-reported child health-related quality of life (77.6 vs 80.0 and 76.1 vs 77.0, respectively), but phonologic short-term memory was poorer (91.0 vs 102.8) in the sensorineural hearing loss group. CONCLUSIONS: The prevalence of slight/mild bilateral sensorineural hearing loss was lower than reported in previous studies. There was no strong evidence that slight/mild bilateral sensorineural hearing loss affects adversely language, reading, behavior, or health-related quality of life in children who are otherwise healthy and of normal intelligence.

Comparison of auditory steady-state responses and tone-burst auditory brainstem responses in normal babies.

OBJECTIVE: To follow the development of tone-burst auditory brainstem response (TB-ABR) and auditory steady-state response (ASSR) thresholds in a group of normal babies through the first 6 wk of life. DESIGN: This longitudinal study involved assessment at four data-collection points. TB-ABR and ASSR thresholds to 500-Hz and 4-kHz stimuli were established in 17 full-term subjects at 0, 2, 4, and 6 wk of age. Stimulus-modulation rates for ASSR assessment were 74 Hz (for 500-Hz tones) and 95 Hz (for 4-kHz tones). TB-ABR responses were recorded to stimuli presented at 39.1 Hz. RESULTS: Mean ASSR thresholds (calibrated in dBHL) at 500 Hz ranged from 44.4 to 39.7 dB HL across the recording period, and at 4 kHz they ranged from 37.9 to 32.1 dB HL. TB-ABR thresholds (calibrated in dBnHL) were significantly lower, ranging from 36.8 to 36.2 dB nHL at 500 Hz and from 16.5 to 15.9 dB nHL at 4 kHz. However, when the stimuli used for each test were calibrated in the same units (peak equivalent dB SPL), the results were similar. That is, the differences between the two techniques were only an artifact of the calibration. ASSR thresholds were more variable than TB-ABR, particularly at the neonatal measurement point. Within-subject changes across the test period were observed for ASSR thresholds but not for TB-ABR. CONCLUSIONS: The longitudinal findings presented in this study suggest that for normal neonates, the TB-ABR technique may offer a more reliable basis for prediction of hearing levels than ASSR assessment. This is not because TB-ABR thresholds (calibrated in dBnHL) are lower, but because the response is less affected by maturational development in the first weeks of life and is less variable across subjects.

The distraction test: the last word?

OBJECTIVE: Universal Newborn Hearing Screening (UNHS) programmes have been widely implemented, but their costs, benefits and long-term logistics remain to be clearly defined. There are few rigorous evaluations of alternative strategies. In this paper, we evaluate the performance of the distraction test component of the two-tiered Victorian Infant Hearing Screening Program (VIHSP). METHODS: All babies born in the State of Victoria, Australia in 1993 who survived the neonatal period were screened for the presence of risk factors for hearing loss. Those at-risk were referred for Auditory Brainstem Evoked Response (ABR) screening by a professional audiologist. All others were screened by modified distraction test at age 7-9 months. This birth cohort was followed through age 6 for diagnoses of congenital hearing loss resulting in fitting of hearing aids. Estimates of false-positives, false-negatives, sensitivity, specificity and positive predictive values were determined for the distraction test as a population screen. Ages at diagnosis and aid fitting for screen failures with hearing loss were compared with current goals. RESULTS: For targeted (moderate or greater-aided) losses, the distraction test yielded eight (0.02%) documented false-negatives (one severe and seven moderate) and an estimated 4265 (99%) false-positives. Distraction test sensitivity was 65%, specificity 91% and PPV 0.3%. Mean age at diagnosis for distraction test failures across all severities, including mild losses, was 23 (SD 18) months with a mean age at aid fitting of 26 (SD 20) months. CONCLUSIONS: The distraction test screen generated large numbers of false-positives and a significant number of false-negatives, performing particularly poorly with moderate losses. Ages at diagnosis and aid fitting for screen failures were far older than currently accepted goals. There is little evidence that the distraction test can be made to work acceptably as a population-based screen.

Outcomes of children with mild-profound congenital hearing loss at 7 to 8 years: a population study.

OBJECTIVES: Improved long-term outcomes of hearing loss at a population level is the underlying reason for interventions such as newborn hearing screening programs. Therefore, high-quality population surveys are needed for older children across the spectrum of hearing losses that might be detected by such programs, against which to assess future secular improvements. Measured outcomes should cover a broad range of parameters, including health-related quality of life. DESIGN: Population-based cohort study (CHIVOS, the Children with Hearing Impairment in Victoria Outcome Study). SETTING: State of Victoria, Australia. PARTICIPANTS: Eighty-six 7- to 8-yr-old children born in Victoria, who were (a) fitted with hearing aids for congenital hearing loss by 4.5 yr and (b) had no intellectual or major physical disability. MEASURES: Standardized measures of language (CELF and PPVT), articulation (Goldman-Fristoe Test of Articulation), cognition (WISC), reading, adaptive functioning, health-related quality of life, parent developmental concerns, parent- and teacher-reported intelligibility and behavior, and teacher-reported school functioning. RESULTS: Response rate was 67% (N = 89). Of the 86 able to be included in analyses, 53 were boys; 22% had mild, 31% moderate, 17% severe, and 29% profound hearing loss; the mean nonverbal IQ was 104.6 (SD 16.7). The sample scored far below (1.3 to 1.7 SDs) the normative populations on the PPVT and on the Receptive, Expressive and Total CELF scores. On average, children's reading age was delayed nearly 10 mo. For every outcome measure except physical health, these children scored significantly worse than the relevant normative population. Language and vocabulary scores worsened with increasing severity of hearing loss, but adaptive functioning, health-related quality of life, academic skills and behavior did not. CONCLUSIONS: Comprehensive data such as these highlight the continuing plight experienced by hearing-impaired children, and will help evaluate over time whether outcomes for children with hearing loss are improving at a population level.

Epidemiology of congenital hearing loss in Victoria, Australia.

The aim of this study was to report the incidence, prevalence and clinical characteristics of congenital hearing loss sufficient to require hearing aid fitting in the first 6 years of life for the 1993 birth cohort of the state of Victoria (population 4.4 million), Australia. In 1993, 64,116 infants born in the state of Victoria survived the neonatal period. Subjects included all children with congenital hearing loss for which hearing aids were fitted, at any time up to and including 31 December 1999, when the youngest member of the cohort reached 6 years of age. Data on the degree, type and etiology of hearing loss were available from the Australian Hearing database for all subjects. Sociodemographic and health data were available from the Victorian Infant Hearing Screening Program (VIHSP) and parent questionnaires. The known prevalence of identified congenital hearing loss increased as the cohort aged. By the time the youngest member had reached the age of 6 years, 134 children (78 boys, 56 girls) had been fitted with hearing aids for permanent congenital hearing loss of any degree (2.09/1000). Fifty-four (40%) of these had known mild losses (20-40 dB HL). The prevalence of known moderate or greater loss (> 40 dB HL) was 1.12/1000; the data suggest that over 90% could have been detectable by neonatal hearing screening. A further seven children from the birth cohort were fitted with hearing aids due to acquired forms of hearing loss (0.11/1000). The etiology was known in only 57 (43%) congenital cases, with known non-syndromal genetic causes accounting for 21 (37%) of these. This study reports on the prevalence of congenital hearing loss requiring hearing aid fitting for an entire birth cohort. These data indicate the possible yield from neonatal screening, and hence the likely benefit of such screening. For a large proportion of cases, the etiology remains unknown. These data have implications for health service delivery and illustrate the usefulness of a population database in monitoring the prevalence of congenital hearing loss.

Prediction of hearing threshold in infants using auditory steady-state evoked potentials.

This retrospective study examines the relationship between auditory steady-state evoked potential (ASSEP) thresholds determined in infancy and subsequently obtained behavioral hearing levels in children with normal hearing or varying degrees of sensorineural hearing loss. Overall, the results from 211 subjects showed that the two test techniques were highly correlated, with Pearson r values exceeding .95 at each of the audiometric test frequencies between 500 and 4000 Hz. Analysis of the findings for babies with significant hearing loss (moderate to profound levels) showed similar threshold relationships to those obtained in previous studies involving adults and older children. The results for infants with normal or near-normal hearing did, however, differ from those reported for older subjects, with behavioral thresholds typically 10 to 15 dB better than would have been predicted from their ASSEP levels.

The auditory steady-state response: full-term and premature neonates.

Two studies were aimed at developing the auditory steady-state response (ASSR) for universal newborn hearing screening. First, neonates who had passed auditory brainstem response, transient evoked otoacoustic emission, and distortion-product otoacoustic emission tests were also tested with ASSRs using modulated tones that varied in frequency and level. Pass rates were highest (> 90%) for amplitude-modulated tones presented at levels > or = 69 dB SPL. The effect of modulation frequency on ASSR for 500- and 2000-Hz tones was evaluated in full-term and premature infants in the second study. Full-term infants had higher pass rates for 2000-Hz tones amplitude modulated at 74 to 106 Hz compared with pass rates for a 500-Hz tone modulated at 58 to 90 Hz. Premature infants had lower pass rates than full-term infants for both carrier frequencies. Systematic investigation of ASSR threshold and the effect of modulation frequency in neonates is needed to adapt the technique for screening.

The auditory steady-state response: clinical observations and applications in infants and children.

Two studies illustrate the use of the auditory steady-state response (ASSR) in the pediatric clinical audiology setting. A protocol for estimating bone-conduction thresholds from ASSR was developed. Bone-conducted narrow-band noise was used to mask the ASSR for a 1.0-kHz modulated tone. The amount of bone-conducted noise needed to mask the ASSR may distinguish between infants and children with conductive hearing losses and those with sensory losses. The amount of bone-conducted noise may also be used to estimate bone-conduction thresholds; however, the accuracy of this technique needs verification with behavioral methods to determine thresholds for bone-conducted pure tones in infants. When ASSR tests are used as part of the diagnostic evaluation for infants and children at risk for hearing loss, the results yield information about the audiometric contour and residual hearing, which aid in treatment and habilitation decisions.

Inclusion of students who are deaf or hard of hearing in government schools in new South wales, australia: development and implementation of a policy.

The inclusion of students who are deaf or hard of hearing in Department of Education and Training (government) schools in the state of New South Wales, Australia, is supported through a policy known as the Special Education Policy (NSW Department of School Education, 1993). The policy is operational for all students with disabilities, learning difficulties, or behavior disorders, regardless of their educational provision. This article focuses on how the policy and continuum of services have developed and the attitudes of stakeholders toward both policy and practice. The article begins by framing the policy in terms of legal mandates and then gives an overview of current educational provisions, followed by a discussion of attitudes toward inclusion as held by stakeholders in New South Wales government schools. The article concludes by attempting to assess the potential effects of both policy and practice on students who are deaf or hard of hearing.